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1 Prince of Peace Center P. O. Box Darr Ave. Farrell, PA Program Application for: 1 Referred by HOPE FAITH Head of Household Information Gender Male Female Last name First name Marital Status Married Single of Birth Address Age Ethnicity Black Hispanic Asian White Native Arabic American City State Zip Telephone #1 Telephone #2 Social Security # tes: Employment Status Full-time Unemployed Student Part-time Disabled Retired Please check all items that you currently have: Driver's License State ID Card Medical Card Birth Certificate(s) Social Security Card(s) List other adults living in home (18 +): of Birth Age Gender Social Security # Ethnicity List children living in home (under 18): of Birth Age Gender Social Security # Ethnicity Please briefly explain why you are applying for FSS:
2 2 Housing Information Are you currently homeless? May we contact your landlord? If yes, for how long? Have you ever been evicted or verbally asked to vacate any past residence? If yes, please provide: Landlord s name: Do you have a copy of the eviction notice? Phone: What is your primary residence for the past 30 days? Please check all housing programs for which you have applied: Own Residence Section 8 : With Friends / Relatives Public Housing MCHA : Jail / Prison Private Landlord : Hospital Centennial Place : Shelter Orange Village : Street / Car / Vacant Building Reynolds West : Treatment Facility / Group Home Shenango Park : Willow Village : Actual Household Income (last 30 days): Employment Welfare Food Stamps SSI/SSD Unemployment Child Support Retirement/Pension Monthly Total Past Due Expenses: Rent Electric Gas Water Sewer Phone Medical Auto
3 3 Medical Information Have you had a physical exam in the past year? Do you have a personal physician? Have you had an eye exam in the past year? If yes, please provide: Have you had a dental exam in the past year Name: Have you ever had a positive tuberculosis (TB) skin test? Do you currently have or have a history of infectious/communicable diseases? If yes, please specify: Address: Phone: Are you pregnant? YES NO If yes, are you receiving prenatal care? YES NO When is your due date? Name of physician: Check all of the following medical diagnoses you have or have had: Anxiety Asthma Bipolar Cancer Depression Diabetes Epilepsy Seizures High Blood Pressure Heart Trouble Hepatitis ( A B C ) Pneumonia Suicidal thoughts Homicidal thoughts Have you been hospitalized for any of the above? When: Are you receiving treatment now for any of the above? Name of physician/practice: Where: Please list all medications you are currently taking: MEDICATION NAME MEDICATION PURPOSE
4 4 Other Information What is your highest educational grade completed? Are you currently on probation or parole? If yes, for how much longer? Do you have any fines to pay? If yes, list balance(s): Have you been convicted of a felony? If yes, list charge(s): Have you experienced trauma, including physical or sexual abuse? If yes, please explain: Check all of the following you have used in your lifetime: Alcohol Amphetamines Cocaine Crack Hallucinogens Heroin/Opiates Marijuana PCP/LSD Tobacco Methadone When? What was/were the last drug(s) you used? Substance abuse interventions you have had: ne Inpatient Outpatient Drugs Alcohol Both Can you pass a drug test today? What services are you currently involved in (Family Center, Literacy Council, Career Link, WIC, etc.)? What goals would you like to accomplish by participating in FSS? What barriers are you facing that keep you in your current situation?
5 5 Please list three personal strengths and three personal weaknesses: Personal Strengths Personal Weaknesses Please list at least three (3) people that you have known for at least six months, who can attest to your character (personal or professional): Name Phone Relationship In case of emergency, we should contact: Name: Address: Phone: The information that I have provided on this application is true. I understand that any false or misleading information may result in termination from the HOPE Advocacy or FAITH Initiative programs, should I be enrolled as a participant. Applicant s Signature Director s Signature
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